The Concussion Panic

Why are we so convinced that football head injuries lead to suicide?

When ex-NFL star Junior Seau took a shotgun to his sternum last week, commentators called it a "sobering wake-up call" for the league. How could a never-say-die athlete, a proven winner on the field, give up his own life? My Slate colleague Josh Levin wondered whether this latest football suicide would finally change the way we think about the consequences of repeated head trauma.

That wake-up call may have arrived Wednesday morning. News outlets (including this one) have suddenly became aware of some surprising and important CDC research published in January in the American Journal of Cardiology. At the request of the NFL Players Association, government scientists compared the death rates for almost 3,500 of the league's retirees to those for age- and race-matched non-athletes over the same years. The football players had much longer lives: Just 334 of them had passed away, compared with an expected total of 625.

What does this have to do with Junior Seau? The CDC study was designed to look for fatal cases of cardiovascular disease among the athletes. (It found one-third fewer than expected.) But the researchers also compiled numbers for more than a dozen other categories of disease and injury, including suicide. Former players were 42 percent less likely to die of cancer, 86 percent less likely to die of tuberculosis, and 73 percent less likely to die from digestive problems. And among the athletes who regularly played professional football between 1959 and 1988, a total of nine perished as a result of "intentional self-harm," compared with an expected number of about 22. The sample size was small, but the effect is large: Ex-NFLers were 59 percent less likely to commit suicide.

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This is, so far as I know, the first major attempt to compare suicide rates among former football players with those in the general population. And while it's risky to draw too many conclusions from a single study—just a handful of deaths, really, among players from a bygone era—the news from the CDC challenges the prevailing narrative about Junior Seau and all the other aging athletes who killed themselves in recent years. It's now speculated, assumed, and even asserted outright that repeated knocks to the head leave football players with a condition called chronic traumatic encephalopathy (CTE), and that this form of brain damage—diagnosed in the autopsied remains of ex-players like Dave Duerson and Andre Waters—might have caused their downward spiral into depression and suicide.

We don't need the CDC numbers to tell us that the national debate over head trauma and suicide has long since outpaced the scientific evidence. Just a handful of cases so far support the notion that repeated head injuries (concussive or otherwise) can lead to drug abuse, aggression, and self-harm. No one knows the baseline rate of chronic traumatic encephalopathy among athletes, let alone the general population. No one knows whether the pathological signs of CTE—microscopic spots in the brain, found after death—relate to behavioral symptoms like dementia and depression. And no one can explain how repeated knocks to the head might produce CTE, or how CTE might produce suicidal thoughts. Yet in spite of our near-total ignorance, a moral panic has taken hold: Elaborate explanations are concocted when simple ones will do. Faced with the regrettable facts—a troubled man dies a lonely death—we resort to hocus-pocus theorizing about tau proteins and fibrillary tangles. It's a form of denial: By obsessing over hidden trauma, we ignore what's right in front of us. Many ex-NFL players have sad and difficult lives.

Physical and mental problems endemic among ex-athletes may have increased the burden on Seau. In 2007, researchers from the University of Michigan sent questionnaires to several thousand retired football players and found that half were experiencing severe pain on a regular basis; 15 percent said they were either moderately or severely depressed. For a more recent study, Linda Cottler, then of Washington University, called up 644 former NFL players, and learned they were using prescription painkillers at four times the rate of the general population. Three-quarters said they "had severe pain," and almost as many described themselves as suffering from moderate to severe physical impairment.

Chronic, physical discomfort happens to be a major risk factor for suicide. People on painkillers are also more likely to be addicted to drugs—a risk factor in itself—and they're also known to have a higher success rate when they do attempt suicide. Even just the feeling of poor health can make people more inclined to hurt themselves.

Permanent injuries may be even more devastating to former athletes, who once relied on their superior physical conditioning to make a living. One-time tennis star Jennifer Capriati didn't suffer much head trauma on the clay and grass, but repeated injuries to her shoulder and wrist eventually forced her out of the game. In 2010, she experienced what was described as an "accidental overdose" on painkillers; according to one friend, she'd been "in tremendous pain physically and mentally" since retiring.

Or consider the story of the hockey enforcer Derek Boogaard, written up last December in a Pulitzer-nominated series for the New York Times. After years of bare-knuckled brawling on the ice, writes John Branch, Boogaard's hand was a mess: "The fingers were bent and the knuckles were fat and bloody with scar tissue, as if rescued a moment too late from a meat grinder." It was a condition that left him strung out on painkillers, and in and out of drug rehab. He died from an overdose in 2011.

Yet no one seems willing to blame Boogaard's death on his mangled hand. Branch invokes "a brain going bad"—and a postmortem diagnosis of CTE—to explain what happened: Boogaard, he suggests, suffered from numerous concussions that might have made him more prone to dangerous substance abuse. But there's a more parsimonious explanation for the facts: Perhaps it wasn't Boogaard's broken head that led him to addiction, but his fist.

Another example: Former defensive back Andre Waters shot himself in the head in 2006, at 44 years old. He, too, would later be diagnosed with CTE. But once again, there are simpler—and more believable—ways to account for what happened. A reporter who spoke with Waters not long before the suicide reported that "every part of his body hurt, and he knew which collision or injury from his career was at the root of it." He'd been involved in a four-year battle over the custody of his daughter, and like many other retired athletes, he suffered the boredom and regret of a life now spent on the sidelines. "When you're playing football it tastes like honey," he told the reporter, "and it goes down sour like a lemon when you're not."

Why am I so willing to discount brain trauma as a cause of suicide? Pathologists at the Boston University Center for the Study of Traumatic Encephalopathy studied the brains of a dozen former football players who died between February 2008 and June 2010 and found the signs of CTE in every single one. In addition to those 12, 309 other ex-players are known to have died during that interval. According to the BU group, that means CTE affects at least 3.7 percent of the population. (It's basic math: 12 divided by 321 is 0.037.) But this ignores a more disturbing, confusing possibility. What if most of the other 309 dead players had the tell-tale signs of CTE in their brains? In total, the group has found evidence of the disease in more than two-thirds of the ex-athletes they’ve examined. Some people with the condition may never develop any symptoms of cognitive decline, says Brandon Gavett, a neuropsychologist who worked with the team in Boston.

Given that most football players might show these signs of brain damage, even the ones who never dream of suicide, we might do well to withhold our judgment. Yet the moral panic over head trauma rages on. It was announced in publishing circles this week that a pair of investigative reporters, Mark Fainaru-Wada and his brother Steve Fainaru, recently inked a deal to write a book on "the NFL, brain injuries and the science of brutality." The ex-players who are suing the league have compared their former employer to Big Tobacco and made the scandal sound as dire as the controversy over steroid use in baseball.

The comparison is instructive: It wasn't so long ago that we blamed athletes' unexpected deaths on performance-enhancing drugs, not head trauma. When pro wrestler Chris "the Canadian Crippler" Benoit killed his wife and son and then hanged himself in 2007, authorities blamed the incident on anabolic steroids. In 2005, Congress heard testimony from the parents of young athletes who had committed suicide while experiencing the putative effects of steroid withdrawal, and researchers trotted out anecdotal reports to prove the link.

If Junior Seau had killed himself when George W. Bush was still in office, we'd all be talking about the cream and the clear, not CTE. But you don't hear much talk about steroids and suicide today. Is it passé to observe that around 9 percent of NFL retirees admit to having used steroids during their career? The panic over performance-enhancing drugs feels obsolete, like an anxiety from another time.

Though reasonable men can differ on whether football damages the soul, it’s clear that it can tear the nerves. Doctors have been aware of brain trauma in athletes (among boxers in particular) for about a century. They used to call it dementia pugilistica and before that by less scientific names: Athletes were punch drunk; they were slap happy; they were paper dolls, or punchie, or goofy, or slug nutty. And we're finding the same condition among NFL retirees today. Former quarterback Jim McMahon says he's lost his memory. Ex-Giant Harry Carson has headaches and blurred vision. These disabilities, almost certainly brought on by repeated head injuries, are exactly the sorts of things that might drive someone to suicide. Getting a diagnosis of dementia seems to produce feelings of depression and hopelessness, and chronic pain is chronic pain—whether it comes from a twisted spine that's held in place with titanium screws or a concussed brain beset with migraines.

The injuries are real, but we've been knocked in the head over and over again with the idea that head trauma causes suicide by a more direct route. It's not that the symptoms of concussion bring people down; it's that the concussion itself does something to our brains—it disables the neural wiring that prevents normal people from killing themselves. What makes an ex-football player shoot himself? Not his swollen joints or his twisted spine. Not his marital problems or his personal bankruptcy. Not the headaches or the memory loss or the years of drug abuse. It's that some fleshy circuit-breaker in his head has been knocked offline—a sprained amygdala, a broken frontal lobe, a locus coeruleus in disrepair.

Why are we so entranced by these brain-based explanations for suicide, when so many others would do just fine? A collusion of self-interest motivates this belief, and it starts with the players themselves. When former defensive back Dave Duerson killed himself in 2011, there were, as usual, plenty of causes for his misery: Both his parents had died not long before, flubbed business deals had forced him into bankruptcy, and he'd suffered through a divorce amid charges of domestic abuse. But Duerson wanted us to know that his suicide wasn't a sign of weakness, that he hadn't given up in the face of all his woes. Like Seau, he pointed a gun at his chest, so his brain would be preserved for study. He wanted us to know that his brain made him do it.

As fans and onlookers, we also benefit from this just-so story. Instead of confronting the miseries of the retired athlete—the chronic pain, opiate addiction, and unemployment—we siphon off our anxiety over having fueled his rise and fall. We'll make it better by talking about better helmets, new rules for kickoffs, and fancy concussion tests (that may not even work). And we'll forget that brain damage is not a death sentence. Depression can be treated.

Former players kill themselves for the same reason as everyone else—because they're sad and alone and deprived of the psychiatric care that could maybe save their lives. After Andre Waters passed away in 2006, one of his nieces described his mental state for Dave Scheiber of the Tampa Bay Times: "I saw him suffer in silence," she said. "I was right in his midst for three years and every morning he would wake up with this big sigh, it never failed." Waters never sought medication or therapy for his troubles. "He would try to cover it up," she explained, "because he didn't want to bring everyone else down."*

*Correction, May 16, 2012: Originally this article introduced a typo into a quote from the Tampa Bay Times. A niece of Andre Waters said, "... every morning he would wake up with this big sigh," not "with a big sign."